Vaccinarsi in Sardegna

Cervical cancer nowadays represents the fifth most common cancer worldwide, and, with an age-standardized incidence rate of 13.3 per 100,000 women (2020), is responsible for hundreds of thousands of deaths each year. Moreover, HPV infection is associated with the development of numerous other cancers of the uro-genital (vulva, vagina, penis, anus) and head-neck (oropharynx) region, as well as benign but high-impact quality-of-life lesions, such as ano-genital condylomas. This further aggravates the burden of disease produced by this infection, which can be prevented by primary and secondary prevention interventions: vaccination and screening, respectively.

However, despite the strong evidence supporting the importance of prevention as a powerful life-saving weapon, in Europe and Italy HPV vaccination coverage in girls and boys, already far from the 95% target in previous years, declined further in 2020 (2008 birth cohort), due to the strong impact of the pandemic on vaccination activities (particularly pronounced precisely towards adolescent and adult vaccinations).

A similar impact has also occurred with respect to cervical cancer screening activities, so the need to implement all possible actions to effectively revive the message related to the essentiality of informed adherence to vaccination and scheduled screening programs appears crucial.

In the Sardinian territorial context, papilloma virus (anti-HPV) vaccination has been actively offered free-of- charge since 2008 to girls in their twelfth year of life (eleven years of age); and this offer is extended to the cohort beyond this year. The outgoing National Plan for Vaccine Prevention (NPPV) 2017-2019 set a target of 95% for girls in the twelfth year of life and extended vaccination to boys in their twelfth year, and the current Plan 2023-2025 reiterates the content of previous plans in light of the past pandemic context.

Sardinia exceeded the 70 percent target for the 2001 cohort, but thereafter coverage has been declining. It is lower in the latest cohort (2006) than in previous cohorts (1997 was the first cohort to be actively invited, in 2008) where catch-up activity continues. Overall it is below the PNPV optimal threshold (95%) and the national average (24.68% Sardinia vs 40.34% Italy in the last year).

Therefore, the region of Sardinia, with the Regional Vaccine Prevention Plan 2020-2025 has chosen to dedicate a Free Program (PL13) to the Consolidation of Organized Cancer Screening Programs, including vaccination.

All actors involved in vaccination in the region are therefore called upon to adopt the best catch-up strategies in order to achieve the coveted vaccination coverage (with associated recoveries) in the shortest period.

In this regard, VaccinarSinSardegna.org reports the statement of the Head of S.S. Vaccinations A.S.L. Cagliari, Dr. Gabriele Mereu, who outlines the important initiatives aimed in this direction by the Cagliari ASL.

"With the resolution of the D.G. of the ASL of Cagliari No. 114 dated 12/02/24, the "Project for the use of the staff of the medical management and the branch, as part of the implementation of activities related to the recruitment and active invitation to HPV vaccination in the target population for the period 01/01/24-31/12/24" was initiated. This project is included in the Regional Prevention Plan 2020-2025 - PL 13-Screening for prevention of cervical cancer - Action 4 - Free HPV vaccine offer. This plan allows for the implementation of an extraordinary HPV vaccination program with the 'goal of achieving vaccination coverage such as to reduce the impact in the target population of HPV-related cancer diseases, particularly cervical cancer. This is a key opportunity to bridge the large gap between what is indicated by the new PNPV that provides for 95% coverage in the adolescent population and the current coverage which is far lower in Sardinia than in the rest of Italy. The project also includes vaccination of women with HPV-related pre-cancerous lesions in order to prevent cancer recurrence.

HPV vaccination, as well as other vaccinations in adolescence, has the lowest coverage. There are several reasons for this, and only by acting on the causes can our program be fully realized, in particular:

• Vaccination against COVID-19 has generated a kind of vaccination fatigue in the population giving rise to a resurgence of bad information by the "no vax" movement.
• HPV vaccination was among those most neglected during the COVID-19 emergency because, in a situation of reduced operation of vaccination clinics, priority was given to immunization of children.
• Media communication to families and adolescents about cancer risk and vaccine benefit has not been sufficient. In particular, those modern and user-friendly media that respond to the language used by today's youth but also by young parents (videos, apps, social media etc.) have not been adequately exploited
• Communication, which was not limited to just a "reminder" to vaccinate by prevention departments, GPs, PLSs, counselors, gynecologic oncologists was not sufficiently widespread or in-depth, particularly in schools.
• New knowledge about HPV and vaccine characteristics is not always adequate among users but also among various health care providers.
• Adolescent vaccination involves objective access difficulties due to attending classes, doing homework or playing sports, difficulties often compounded by the distance of the home from the vaccine hub.
• Adolescent vaccination requires the consent of the vaccinee as well as the parents.
• There is still a misconception among parents that their children, particularly those in the 11-15 age group, are not at risk of infection because they are too young to have sexual intercourse (statistics, however, confirm the opposite).
• HPV vaccination is not mandatory, and therefore considered of lesser importance than others.

Therefore, given the current context, the basic conditions that must be realized for the project to succeed, and on which we strive to have the greatest impact, are as follows.

1. Appropriate communication to the vaccinee and parents by PLSs, GPs, District workers (counseling centers, outpatient clinic specialists especially pediatricians, gynecologists, obstetricians, health care assistants, oncologists).
2. Communication to students and teachers through meetings in schools by, in particular, counseling staff.
3. Use for dissemination purposes of the media, especially local television and print media.
4. Correct information for vaccinees and their parents via social media, video apps, posters with QR codes.
5. Implementation of training for health workers in Prevention Departments and Districts.
6. Active call - co-commitments
7. Open days.
8. Establishment of a dedicated e-mail "vaccinazionehpv@aslcagliari.it" in addition to the general e-mail for vaccinations vaccinazioni@aslcagliari.it
9. Outpatient activity with ease of 'access both in terms of hours, days of the week and location of vaccination sites (vaccination in the territory, in counseling centers, in specialized outpatient clinics, in the hospital, at the caregiver etc.)."

VaccinarSinSardegna.org on this important anniversary reiterates even more firmly the importance of health education and vaccination communication essential to address the stigma attached to this disease, which still represents a dangerous barrier to overcome, especially in reaching such a difficult-to-intercept audience as adolescents and young adults at whom the HPV vaccination is mainly aimed.

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